12-week Outpatient Physical Therapy Intervention Program for a 14-year-old Male with

Spastic Quadriplegia to Assist with Transfers

Author: Amanda J. James

Research Advisor: Linda M. Hall PT, MS, DPT

Doctoral program in Physical Therapy

Central Michigan University

Mount, Pleasant, Michigan

Date: December 23, 2023

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctoral of Physical Therapy

Accepted by the Faculty Research Advisor

Linda M. Hall PT, MS, DPT

Linda M. Hall PT, MS, DPT

Date of Approval: March 23, 2024

 Abstract

Background and Purpose: Out of all childhood conditions Cerebral Palsy is considered the

most common condition affecting every 2-3 births out of 1000. Symptoms of Cerebral Palsy vary

depending on the brain involved, and the severity of Cerebral Palsy symptoms can include

muscle tightness, tone, tremors, or involuntary motor movements, and weakness. There are

multiple types of Cerebral Palsy including hypotonic Cerebral Palsy, spastic diplegia Cerebral

Palsy, and spastic quadriplegia Cerebral Palsy. Children with Cerebral Palsy level of disability is

graded using the Gross Motor Functional Classification System (GMFCS). There is some

research available that suggests creating functional and goal-oriented plan of care or benefits of

using manual therapy. However, most studies do not look at combining different interventions

together as most focused on a specific type of therapy. Therefore, the purpose of this case report

was to determine if using functional strengthening training paired with stretching, manual

therapy and vibration therapy can improve functional outcomes in a 14-year-old boy with level 4

spastic quadriplegia Cerebral Palsy.

Case Description: The patient was a 14-year-old male with spastic quadriplegia Cerebral Palsy.

He presents with a GMFCS level of 4. He was part of a quintuplet pregnancy, and he suffered a

brain bleed at birth. He uses a manual wheelchair to get around or crawls. His mother helps

perform standing pivot transfers in the bathroom and into bed. The patient’s mother reports

decreased lower extremity strength during transfers requiring her to assist more. Her goals

included stretching and strengthening her son’s lower extremities to assist her when transferring

him. Therapeutic activities, manual therapy, and neuromuscular reeducation exercises were used

during sessions.
Outcomes: The patient demonstrated significantly improved range of motion in bilateral lower

extremities. He also had improved abilities to transfer himself out of his wheelchair safely and

required less assistance from the physical therapist when a given transfer required assistance. His

strength was also significantly improved because of his 5TSTS completion time.

Discussion: In this study, stretching, strengthening, and vibration plate therapy was used to

improve function and transfer ability in a child with Cerebral Palsy. Results of this study

included improvements in bilateral knee extension PROM, popliteal angle, and the patient’s

5TSTS assistance level. Improvements in PROM and popliteal angle allowed the patient

improved ability to stand up for transferring. The patient’s 5TSTS also showed significant

improvement in time and assistance level. He could safely and effectively assist the therapist

with transfers throughout the session, even completed transfers from wheelchair to mat with only

stand-by assist and a step to place his feet when shifting from wheelchair to mat.
Background and Purpose

Out of all childhood conditions Cerebral Palsy is considered the most common1. For

every 1000 people born, 2-3 will be diagnosed with Cerebral Palsy; therefore, there are 8000-

10000 babies and infants each year diagnosed with Cerebral Palsy2. Symptoms of Cerebral Palsy

vary depending on the part of the brain involved and the severity of Cerebral Palsy, for example

diplegic or quadriplegic Cerebral Palsy3-5. Symptoms that can be noted include muscles tightness,

tone, tremors or involuntary motor movements and weakness3,6. There are multiple types of

Cerebral Palsy including hypotonic Cerebral Palsy, spastic diplegia Cerebral Palsy, and spastic

quadriplegia Cerebral Palsy. Hypotonic Cerebral palsy is when a patient has damage to the

cerebellum. Symptoms of hypotonic Cerebral Palsy include low tone, poor balance, ligament and

joint laxity5. Spastic Cerebral Palsy is when there is damage to the motor cortex and pyramidal

tracts4. Spastic diplegia is when two limbs typically the legs are involved4. Spastic quadriplegia

is when all four limbs and potentially the face are involved4. Spastic quadriplegia accounts for

20% of individuals with Cerebral Palsy and 90% of individuals with Cerebral Palsy have

spasticity2,7.

The Gross Motor Function Classification System (GMFCS) is used to determine a child

with Cerebral Palsy current level of function8. It also helps to provide insight into assistive

equipment that a child may need throughout their lifespan8. Level 1 is when a child can walk

inside and outside, they can climb stairs without hand support, run, and jump. They tend to

present with decreased speed, balance, and coordination as well8. Children with level 2 Cerebral

Palsy can walk inside and outside, use stairs with hand support, they have some ability to run and

jump. They also have difficulties in crowded areas, inclines and non-level surface s. Children with

level 3 walk with an assistive device on level surfaces, use railings on the stairs, and they may

1
use a manual wheelchair and require some assistance for long distances and uneven surfaces.

Children at level 4 have limited walking ability and they use assistive devices if they do 8. These

children use a wheelchair most of the time and may even use a power wheelchair they can propel

on their own. They may assist with standing transfers as well8. The last level and the most severe

is level 5. These children show impairments in voluntary control against gravity, impaired motor

function grossly, they cannot sit or stand independently, and they cannot walk8. A thorough

breakdown with pictures and descriptions of each level can be found in figure 1. Children over

the age of 5 typically do not change GMFCS level8. The mobility level that a child is at age five

tends to lay out the level of assist and assistive device for the rest of the child’s life 8. Keeping

one’s ability to perform tasks at a given level is particularly important. If someone loses the

ability to assist in transfers, this causes added stress and work on the child and caregiver.

A clinical practice guideline has been created for physical therapy for treating individuals

with Cerebral Palsy9. Jackman and colleagues completed a systemic review comprising 80% of

individuals with Cerebral Palsy who were age 2-18. Within the practice guideline they state to

ensure patient and family centered care9,10. This ensures that all involved feel like they are being

included in creating the program. It also states to make the treatment functional and to practice

the task in its entirety when possible9. This allows for the best translation of success when

completing a task. For example, if the goal is to assist with transfers and they perform standing

pivot transfers, working on sit to stands would be beneficial because that is within the functional

task. Once there is enough strength, working on standing pivot transfer with patient and family

would be best. Other research from McCoy and colleagues involved 656 individuals with

Cerebral Palsy aged 1 year and 6 months to 11 years and 11 months. McCoy et al suggests that

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working on relaxation of spasticity with stretching, improving strength, and activities will

improve self-initiated task and self-care10.

A study done by Chaovalit and colleagues found that working on sit to stand training in

individuals with GMFCS levels 3 or 4 was beneficial to patient’s mobility and caregiver strain.

The individuals in this study completed 75 sit to stands with or without assistance per session

because this was the goal of the study. They did find improvements in a child’s mobility and a

decrease in caregiver strain. However, my concern with this is that 75 sit to stands is not the most

feasible in a standard physical therapy session and could be quite fatiguing for both the patient

and therapist assisting.

Another study looking at different manual therapy techniques including passive

stretching, myofascial release, and functional massage have been used in treatment with

individuals with varying GMFCS levels of Cerebral Palsy9,11,12. These techniques can be used to

relax a patient, improve range of motion and decrease spasticity. There has been a lot of research

for physical therapy and treating people with Cerebral Palsy that states exercises should be

functional to be beneficial and goal oriented. There are also individual studies for specific

interventions such as strengthening or stretching. However, there is not a lot of research that

looks at functional outcomes when incorporating all these interventions together in a treatment

plan.

The purpose of this case report was to determine if using functional strengthening

training paired with stretching, manual therapy and vibration therapy can improve functional

outcomes in a 14-year-old boy with level 4 spastic quadriplegia Cerebral Palsy.

Prior to preparing this report, assent was obtained from the patient and consent was

obtained from the patient’s mother to proceed. All information contained in this case report

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meets the Health Insurance Portability Accountability Act (HIPAA) requirements of the clinical

agency for disclosure of protected health information. This case report was completed under the

direction of the Department of Physical Therapy and with oversight of the College of Graduate

Studies at Central Michigan University.

Case Description

Patient History and Systems Review

The patient was a 14-year-old male with level 4 spastic quadriplegia Cerebral Palsy per

the GMFCS classification8 who reported to therapy to help address loss of lower extremity

strength. The patient was born at 24 weeks gestation and was one of a quintuplet birth. Three

siblings were typically developed, and one died at birth. The patient was diagnosed with a brain

bleed at birth and the patient's mother reported that he had patent ductus arteriosus ligation

surgery within the first few weeks after birth. At the time of the evaluation the patient presented

with a stutter that increased with excitement, fear, or curiosity. A stutter is caused by

dysfluencies in speech and the parts of the brain affected are typically the left inferior frontal

gyrus, and the left motor cortex13,14. Excitement, fear, and curiosity can all be considered

stressors whether good or bad. The stutter contributed to an increase in the degree of his

spasticity at times because when he had a hard time getting his thoughts out his lower extremities

would tighten up. Different muscle movements or spasms like clonus can overflow into other

areas of the body15,16. Some of these areas include the muscle in the face15. Due to the patient’s

diagnosis and subsequent functional deficits, he had been in and out of therapy since infancy and

would likely continue to throughout his life.

The patient had received botulinum toxin injections every 3 months since he was 2 years

old. Initially injections were performed in his bilateral hip adductors, and medial hamstring due

4
to the patient’s risk of hip subluxations. Injections progressed to being completed in bilateral

adductors, quadriceps, and calves. The patient also took the following medications: 5 mg/ml of

oral baclofen Amneal Pharmaceutical Inc17, infliximab, nutritional supplements, oxcarbazepine,

and diazepam.

The patient lived with his parents and 3 sisters in a 2-story home. He stayed on the first

floor and his bedroom and bathroom were on the first floor. The patient’s primary method of

mobility was his manual wheelchair. The patient would crawl in the house if not in wheelchair

and was carried out to the car because they did not have a ramp. His mom stated they were

looking at getting one now that he is older, and he was harder to carry. The patient’s mother

assisted with bed, toilet, and shower transfers and she stated that she is doing all the work right

now.

The patient had a good support system at home with his family. He was being home

schooled since the Corona-19 Virus pandemic. Hobbies of the patient included being with family

and playing with his cat. The patient was unable to verbalize goals directly, however, during

conversation with the patient’s mother her goals included building up strength in lower

extremities, and for her son to assist with all transfers.

Clinical Impression 1

Based on the impairments and goals listed on the patient’s intake forms, a physical

therapy diagnosis of generalized weakness was hypothesized. Lower extremity range of motion

and gross functional strength screen would be assessed, along with patient’s ability to assist in

transfers. Range of motion was considered to check to see how the patient’s extremities moved

to provide information on ability to assist with transfers. The patient’s functional strength would

5
be assessed with the five time sit to stand (5TSTS) assessment. The 5TSTS test is an ideal

functional measurement of strength in individuals with Cerebral Palsy as it is task specific 18,19.

Levels of tone would be assessed by the Modified Ashworth scale as this is the gold

standard for measuring spasticity20. The Care and Comfort Caregiver questionnaire will be

provided to the patient’s mother to complete to determine the degree of assistance the patient

needs at current baseline. The Care and Comfort Caregiver questionnaire is a reliable and valid

outcome measure for caregivers of children with a GMFCS score of 3 or above21. Range of

motion, tone, and lower extremity strength would be assessed as these were the primary deficits

affecting his effectiveness to assist with transfers.

This patient would be a good candidate for this case report because he was part of a

multiple birth pregnancy, and presents fluctuating spasticity based on relaxation and degree of

stutter. He also presented with a decline in functional abilities.

Examination

The patient presented to his physical therapy examination with decreased bilateral lower

extremity active range of motion (AROM) and strength upon observation. He was unable to

transfer from wheelchair to mat without assistance from his mom. He also presented with

increased spasticity in bilateral lower extremities once laying supine or sitting edge of mat.

These observed impairments decreased the patient’s independent mobility level by requiring

assistance throughout the day. The patient required assistance in long sitting to maintain an

upright position.

Cognition: Formal cognition testing was not completed. However, the patient’s mother reported

that the patient is unable to write or read. The patient is verbal and is able to follow one step and

6
simple muti step directions. The patient’s speaking abilities sometimes became physically

challenging due to his stutter. He had a difficult time formulating his thoughts into words.

Transfers: In physical therapy there are multiple different levels of assistance that can be

assigned. Levels of assistance included stand by assist where the person providing assistance

does not touch the participant, but they are very close for safety in case assistance is needed22.

Contact guard is the next level on the scale, which requires the person providing assistance to

have contact with participant throughout the activity, but no other assistance is needed. The third

level is minimal assistance where the patient is able to do at least 75% of the work and the

assistance required by the therapist is 25%22. Moderate level of assist is when the participant and

the person providing assistance does 50% of the work22. The last one to address in this case

would be maximum assistance which is when the participant provides 25% of the work and the

person providing assistance completes 75% of the work22. At the time of the initial evaluation the

patient’s mother completed a standing pivot transfer to transfer the patient from wheelchair to the

mat. His mother reported that the patient can reach for mat and push through his foot plates to lift

himself from his wheelchair to the mat on his own. The patient required moderate- maximum

assistance with verbal cueing for proper hand placement on his wheelchair for transferring from

wheelchair to a mat, and mat to his wheelchair.

Range of motion. Range of motion was measured with a goniometer using the parallel lines

method as demonstrated in Clinical Range of Motion Assessment23. The minimal detectable

change (MDC) for use of a goniometer is seven degrees24. Norkin and White report that

goniometry is a valid and reliable measurement, but each joint varies in the degree of reliability

and validity24. Due to Norkin and Whites findings, and the patient’s motivation to participate in

therapy sessions, seven degrees of change was used in this case to determine if the patient’s

7
improvement was clinically significant or not. The patient’s AROM was not assessed due to

increase in spasticity and patient’s ability to follow directions. All passive range of motion

(PROM) assessments were conducted in supine due to the patient’s ability to relax in supine,

ability to follow directions due to his cognitive impairments, and balance deficits.

The patient’s PROM hip flexion on the right was 108° and on the left 115°. His hip

abduction was bilaterally was 5°and hip adduction was 25° bilaterally. His hip internal rotation

on the right was 40°, and on the left 25°. The patient’s hip external rotation bilaterally was 40°.

PROM knee extension on the right was -40° and on the left -30°. The popliteal angle on the right

was -63° and his left was -57°. Ankle PROM dorsiflexion on his right was 18°, and the left was

40°. His plantar flexion for his right was 42° and his left was 45°. From a physical therapy

standpoint, all lower extremity range of motion was decreased from the normal ranges and the

patient demonstrated bilateral tight hamstrings resulting in decreased ability to stand up straight

and assist with everyday tasks like transfers.

Strength. The patient’s lower extremity strength was assessed functionally by completing a five

time sit-to-stand test (5TSTS test). The 5TSTS test has a test-retest reliability of .97 and a

convergent validity of .59 providing moderate correlation to similar test18. Minimal detectable

change for children with Cerebral Palsy on the 5TSTS test is .11 rep/sec18. Due to the patient’s

GMFCS level, physical assist and guarding was provided for safety. The level of assistance and

time required to complete the 5TST test were tracked throughout the plan of care for degree of

improvement. The patient’s initial score on the 5TSTS test was 20.23 seconds with moderate

assistance from therapist. He was not pushing off his wheelchair and was pulling up on the

therapist for leverage. This meant that the patient was relying on the person assisting with the

transfer to complete the transfer. He also was not utilizing his wheelchair to help him in the

8
transfers. Specific manual muscle testing per Berryman-Reese guidelines25 which are considered

the gold standard protocol for strength testing, were not used due to spasticity involvement,

patients being unable to understand how to achieve and maintain testing positions, and family

goals of patient being able to assist with transfers.

Handheld dynamometry is another form of strength testing used and research had found

this is difficult for individuals with Cerebral Palsy19. Functional strength was assessed instead of

standard specific muscle testing because it can tell an examiner a lot of information in one task

including muscle strength, and balance, and can relate to the individual’s activity level and

goals18,19.

Spasticity was assessed using the spasticity angle or R1 and R2 and the Modified Ashworth

scale. Since spasticity is velocity dependent26 to find R1 for dorsiflexion you would quickly

dorsiflex the patient ankle and the first resistance or stop point felt is R1. To find R2 you relax at

the R1 location and then once the spasticity releases you slowly push to the end range which will

be R2. The Modified Ashworth scale is a 5-level scale ranging from 0-4 where 0 is no increase in

tone and a 4 is the affected part is rigid flexion or extension7.The full scale and scoring criteria is

listed in figure 2. To assess, the patient was laying in supine and his lower extremities were

moved in the following direction and then the therapist assessed where within the range the

patient’s spasticity kicked in. The Modified Ashworth scale has intra-reliability for popliteal

angle ranging from .55-.97 and ankle dorsiflexion of .74-.91 for children with Cerebral Palsy20.

Criterion validity using Pearson Correlation value of .07 resulting in a non-significant correlation

to other test for spasticity severity27.

The patient presented with initial spasticity angle for dorsiflexion grade R1 on the right

was -3° and R2 of 25°, and on the left R1equalled 0° and R2 equaled 40°. From a physical

9
therapy standpoint, since the R1 and R2 values are considered far apart this patient demonstrates

spasticity with a velocity component versus contractures where velocity does not factor in 28.

During therapy slow movements were necessary to decrease risk of increasing spasticity during a

movement. Education was provided to the patient and his family on how to complete transitional

movements and transfer tasks effectively to not elicit spasticity. The patient’s initial spasticity

scores on the Modified Ashworth scale were bilateral hip abduction 4, bilateral hip flexion 2,

bilateral knee extension 3, and bilateral ankle dorsiflexion 3 demonstrating significant increase in

tone and passive movement is difficult7.

Outcome measures. The Care and Comfort Caregiver Questionnaire was provided to the

patient’s mother to complete. This questionnaire is designed to gauge the current functional

status of the patient. A copy of the Care and Comfort Caregiver Questionnaire can be found in

the appendix. The Care and Comfort Caregiver questionnaire is a reliable and valid outcome

measure for caregivers of children with a GMFCS score of 3 or above21. Scale reliability was

used to determine internal consistency between items listed and a Cronbach Alpha score of .90

was determined21. When comparing the Care and Comfort Caregiver Questionnaire with the

WeeFIM a negative correlation is found between them due to the variance in questions 21.

However, it is a concise tool to use to measure the level of difficulty of caring for an individual

with Cerebral Palsy from a caregiver perspective21.

Scoring for the personal care section is 1-5 with 1 being very easy and 5 being

impossible. The positioning/transfers section and in the past month are scored 1-5 with 1 being

easy and 5 being impossible with a do-not-use option for questions specific to equipment use.

The comfort in the past month section ranges from 0-5 where 0 is never and 5 is always. The

10
personal care section and the positioning/transfer training also have a section for the caregiver to

provide a percentage of the amount of work the child is able to do in each task. Interpretation of

the Care and Comfort for Caregiver Questionnaire determines the perceived amount of work the

patient is able to do and the degree of difficulty the caregiver believes is present for listed tasks.

It also looks at comfort in a wheelchair and the ability for an individual to position themselves.

The initial score was a 19/95 indicating that the patient’s mother is completing the majority of

activities with ease and the patient is comfortable with his wheelchair positioning. The areas with

the least amount of patient assistance are putting on pants, changing briefs, cleaning buttocks or

perineum with toileting, applying orthotics and transfers. This means that the patient’s mother

was completing most of these tasks herself. The hardest task for the caregiver to complete was

transfers, and the mother reports the patient only completed 50% of the work. This means that

the patient was not assisting much with transfers and transferring the patient is difficult which

coincides with the mother’s goal of working on patient assisting with transfers. The results

confirm the mother’s concerns about transfers and lower extremity strengthening and highlighted

the areas to work on.

Clinical Impression 2

The examination of the patient confirmed that he demonstrated decreased lower

extremity strength, decreased AROM and PROM, and a decreased ability to assist with transfers

impacting his functional status. The patient continued to be a good candidate for this case report

because physical therapy can address the above impairments of generalized weakness and

decreased ability to transfer to achieve patient and family goals4,5,10. The interventions will be

functionally based, patient and family centered, and coincide with clinical practice guidelines 9,10.

These will include functional training, stretching and strengthening 4,5,9,10. The patient’s

11
rehabilitation potential was good based on his history of compliance with physical therapy, the

family’s level of understanding of patient’s diagnosis, and his support system at home.

Interventions for the patient will include therapeutic activities for strengthening,

neuromuscular reeducation exercises to encourage muscle activation and facilitation, and manual

therapy techniques to assist with spasticity levels. Stretching individuals with Cerebral Palsy is

supported by the clinical practice guidelines to help with spasticity along with playing music

during sessions9,26,29. Functional strengthening has been shown to be beneficial to patients as well

because it is more meaningful to the patient and family and is task specific10. Manual techniques

including myofascial release and functional massage had been shown to be beneficial for

individuals with Cerebral Palsy11.

Positive factors for his recovery were that he had therapy before, was motivated and

participated during sessions and has a supportive family to work with him at home. Barriers to

his recovery were his distractibility, and fear of being stretched causing him to not relax as easily

causing his spasticity to increase. Short term goals consisted of transferring from sitting to

standing from different surfaces with moderate physical assistance to assist his mother with

standing pivot transfers in 6 weeks. A second short term goal was to improve bilateral lower

extremity PROM by 5-10 degrees in order to improve upright posture in 6 weeks. One of the

long-term goals for the patient was to transfer from sitting to standing from different surfaces

with minimal assistance in order to further assist his mother with standing pivot transfers in 3-6

months. A second long term goal was to be able to transition from supine to tall kneel with

minimal physical assistance in order to assist his mother with transfers from the floor in 3-6

months. This goal started being addressed at completion of data collection once the patient’s

lower extremity range of motion and strength had improved.

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Interventions

The patient was seen for physical therapy once a week for 45 minutes per session for 12

weeks with a home exercise program to focus on strengthening and range of motion on days

away from therapy. Interventions included therapeutic activities, manual therapy, and

neuromuscular reeducation exercises and stretching. According to Jackman and colleagues,

interventions are needed to directly relate to the clients’ goals, and for GMFCS level 4 exercises

should work on mobility that are goal or task oriented9. See Table 1 for weekly interventions as

performed.

The patient’s preferred music choice was used during sessions to encourage relaxation

during manual therapy and exercises to keep patient relaxed. Music has been shown to help the

brain focus and can help ease muscle tension seen in individuals with Cerebral Palsy29.

Therapeutic activity. Therapeutic activities were chosen to work on because the patient had

functional goals like transfers. This functional task was broken down into sit to stands and then

the transfers were completed in and out of his wheelchair. Sit to stand training was a primary

strengthening exercise as this ability is required for transfers. Sit to stand training has been

shown to minimally improve GMFCS level 3 and 4 mobility and decrease strain put on the

caregivers who assist with transfers30. Repetitions per session were based on patient’s fatigue

level and level of cueing and physical assist needed to perform sit to stands during that session.

Some sessions sit to stands were conducted from his wheelchair, other days from the edge of the

bed based on patient’s fatigue level for the day. This allowed us to work on strengthening from

different surfaces and levels based on patient needs for transfers in his daily life. The patient

tolerated this activity very well as it was something he attempts to do daily and was part of the

family’s goals. For the first few sessions the patient required verbal cueing for hand placement

13
for getting in and out of the wheelchair. Once patient’s ability to transfer began to improve

patient required fewer verbal cues during sessions and by the last session needed cues 1-2 times

during session for his hand placement. Patient’s ability to focus on the task also contributed to

need for verbal cues

Stretching and manual therapy. Working on stretching and manual therapy techniques were

chosen in order to improve the patient’s range of motion to give him the ability to stand up for

transfers, and to be able to get new braces. Manual techniques were used to assist in gaining

range of motion and relaxing the fascial tissue. Stretching and manual techniques are supported

in the research to help improve range of motion and reduce contractures in individuals with

Cerebral Palsy9,11,12,26. The patient’s right lower extremity presented with increased stiffness when

compared to the left.

Myofascial release was performed in supine on the right foot to help loosen the fascial

tissue to allow for stretching foot and ankle. To perform this procedure, the therapist’s hands

were placed on the sides of the patient’s foot with thumbs on the plantar surface. The therapist

moved hands superior and inferior and medial and laterally to locate where resistance was felt,

and then mild pressure was held in that position for 3-5 minutes. The therapist released the hold

when a slight warmth was felt, and the fascial tissue relaxed. Functional massage was performed

in supine on bilateral lower extremities to stretch gastrocnemius. The patient’s knee was slowly

passively extended and the ankle slowly dorsiflexed and held for 3-5 seconds and then the knee

was passively flexed and ankle plantarflexed with a 3-5 second hold. Moving slowly and

rhythmically through these motions with a brief hold at each end was chosen so that his

spasticity was not elicited. Spasticity is velocity dependent so moving quickly through motions

would activate the patient’s tone7,26. The time spent on stretching and manual techniques was

14
determined by how tight the patient was each session compared to the previous sessions. The

patient had increased difficulty relaxing during stretching and required verbal cueing to lay back

and relax on multiple occasions. The Galileo Med 25TT (Novatech Medical, Pforzheim,

Germany)31vibration plate was used at the beginning of each session in order to help relax,

attempt to decrease spasticity, and stretch the patient’s legs before working through treatment for

the day. When the patient relaxed and stretched, and fascial release was conducted, the patient's

observable range of motion improved. During the patient’s 6th visit, the patient presented with

significant spasticity indicated by brief periods of sustained clonus when lying supine on the mat.

During the Galileo session at the beginning of the 6th visit, the patient was standing up straighter

than previously, therefore the therapist did not block the patient’s knees. This resulted in the

patient doing more of the work, potentially increasing his spasticity. Upon completion of

myofascial release and functional massage, the patient’s clonus had disappeared. A picture of the

Galileo used is in figure 3.

Neuromuscular re-education. Neuromuscular re-education exercises were used to work on

balance and building motor patterns for how to get out of his wheelchair and stand up tall to

work on transfers. The Galileo was used to help bilateral lower extremities. Indications for the

use of the Galileo include, strengthening, tone management, and stretching32. Two or three

repetitions at 20HZ for 3 minutes were completed each session starting on visit 3. This helped to

improve stretching, muscle relaxation, and tone. The patient tolerated the Galileo well and

enjoyed using it each session. The number of repetitions completed was based on the patient’s

ability to stand tall and have his heels flat on the platform. The patient really enjoyed this activity

and asked to do it on multiple visits. He was able to follow directions to stand up tall and was

able to do so with the handrail in front of him.

15
 Quadricep muscles are large stabilizer muscles for static standing and balance. They are

used in conjunction with our gluteus maximus to extend knee and hips during standing from a

sitting position33,34. Short arc quads and quad sets were conducted in addition to the Galileo

vibration plate to promote neuromuscular activation and strengthening of the quadriceps to help

with transfers and standing33-35. Quad sets were completed in supine with a small bolster under

bilateral knees, and patients head resting on pillow. However, the patient had difficulty with

understanding how to perform quad sets. He understood how to perform a short arc quad, so the

decision was made to switch exercises from quad sets to short arc quads. Short arc quads were

conducted in supine with both lower extremities resting over bolster and patient’s head resting on

a pillow. Patient was instructed to straighten his leg. He was then able to extend knee over the

bolster completing a short arc quad. Repetitions were determined by how many repetitions the

patient could complete before fatiguing or losing focus. When the patient was fatigued, he was

unable to lift his leg as high as previous repetitions, so the exercises stopped. When he lost his

focus on the exercises a short break was taken to refocus. If unable to stay focused or complete

exercises at the same quality as previous repetitions after break, the exercise was stopped. If the

patient achieved the previous week's repetition limit and was not tired, the therapist added

repetitions until fatigued or proper form was compromised.

The patient followed a physical medicine and rehabilitation doctor at the same time as

therapy to receive botulinum toxin injections every 3 months, and the patient will see an orthotist

for new braces. The patient was home schooled, so he did not receive services in school. Two

days prior to final measurements, the patient received a whole-body bone scan due to the patient

beginning to have pain in the sacroiliac joints. Results did reveal that patient likely has

sacroiliitis bilaterally.

16
Outcomes

Transfers

When the patient’s mother was asked what improvements she saw with the ability of the

patient to assist with transfers she reported that he is helping a lot more and will push off

wheelchair most of the time. During therapy sessions, the patient could transfer self from

wheelchair to mat with stand-by assist at the same height as wheelchair using a step with contact

guard assist. During standing pivot transfers or multiple sit-to-stand transfers he was able to

complete them with minimal-moderate assistance which is an improvement from the initial

evaluation where the patient required moderate- maximum assistance for transfers.

Range of motion

The patient’s lower extremity PROM improvements were as follows. His right knee

extension improved by 27° and his left knee extension improved by 25°. The patient’s right

lower extremity hip abduction improved 6° and his left hip abduction improved 7°. He saw great

improvement in his popliteal angle on the left, improving by 22°. His right popliteal angle

improved by 4°. The patient’s R1 or initial degree of resistance is 0°, or neutral bilaterally. The

patient’s hip flexion decreased to 100° bilaterally due to increased resistance and patient

complaints of pain likely caused by his sacroiliitis. Overall MDC of 7° was met in bilateral lower

extremity range of motion. Hip abduction on the right did not reach MDC as MDC requires an

improvement of 6° and his right popliteal angle only achieved a 4° improvement.

Strength

The patient’s final time on the 5TSTS test was 19.51 seconds which is .72 seconds

improvement from the initial evaluation. The patient is completing this with minimal- moderate

17
assistance and the patient is now pushing off his wheelchair on each of the five repetitions and

leaning forward when standing. MDC was .11 reps/sec, so the MDC for this test was met.

Spasticity

The patient’s final spasticity angle values were dorsiflexion grade R1 bilaterally 0° and R

2 bilaterally 30°. Patient’s Lower extremity Modified Ashworth Scores were bilateral hip flexion

2, bilateral hip abduction 4, bilateral ankle dorsiflexion 3, and bilateral knee extension 2. Of

these measurements, only knee extension changed. Bilateral knee extension improved from a 3

to a 2 indicating that there is improved ability to move the patient through his range of motion.

Outcome Measures

The patient’s mother reports on the Care and Comfort Caregiver Questionnaire that the

patient is now assisting 60% with transfers. This is a 10% improvement from the initial score

meaning that the provided interventions improved the patient’s ability to assist with transfers.

The final score was 23/95 with an increased difficulty with patient’s ability to adjust himself in

his wheelchair and comfort in his wheelchair. After further discussion with the patient’s mother

this increase was a result of the increased pain the patient was experiencing due to the recent

finding of bilateral sacroiliitis. The areas with the least amount of patient assistance are putting

on pants, changing briefs, cleaning buttocks or perineum with toileting, applying orthotics. These

are the same as previously and are typically seen as occupational therapy activities and were not

goals of the patient’s mother.

The patient goal of transferring from sitting to standing from different surfaces with

moderate physical assist to assist his mother with standing pivot transfers in 6 weeks was met as

patient was completing this with minimal-moderate assistance from therapist or mother. The

second short term goal to improve bilateral lower extremity PROM by 5-10 degrees in order to

18
improve standing upright posture in 6 weeks was grossly met in bilateral lower extremities. The

first long-term goal of transferring from sitting to standing from different surfaces with minimal

assistance to further assist his mother with standing pivot transfers in 3-6 months was also met.

The patient has improved ability to stand up taller for transfers allowing for more assist from the

patient and less strain on the person assisting. A second long-term goal was to transition from

supine to tall kneel with minimal physical assistance to assist mother with transfers from the

floor in 3-6 months. This goal started being addressed at completion of data collection once

patient’s lower extremity range of motion and strength improved and will be continued to be

work on.

Discussion

Cerebral Palsy is the most common diagnosed childhood condition1. There is a lot of

research for therapy on GMFCS levels 1-3 but not as much for levels 4-5. When looking at the

research, most focused on one intervention at a time and do not address combining multiple

interventions to improve functional goals. This study was needed to see if combining

interventions that work on their own can improve overall functional outcomes for individuals

with Cerebral Palsy. By combining interventions as completed in this case report it will be able

to provide more possibilities for improving functional outcomes in individuals with Cerebral

Palsy with higher GMFCS levels. Therefore, the purpose of this case report was to determine if

using functional exercises, manual therapy, and vibration therapy would help to improve

functional outcomes like transfer ability in a 14-year-old boy with level 4 spastic quadriplegia

Cerebral Palsy.

19
 In this study, stretching, strengthening, and vibration plate therapy was used to attempt to

improve overall function for a 14-year-old boy with level 4 spastic quadriplegic Cerebral Palsy.

The most important results of this study were the patients bilateral knee extension PROM

improvement, popliteal angle and the patient’s 5TSTS assistance level. Since there was

significant improvement in the patient’s ability to straighten his legs, it allowed for more upright

posture on the vibration plate which resulted in increased weightbearing on the vibration plate. It

also allowed the patient to stand up with improved upright posture during transfers allowing for

less work by the individual assisting. The patient’s 5TSTS also showed significant improvement

in time and assistance level. The patient was able to improve mechanics for transfers in and out

of a wheelchair including pushing off or reaching for his wheelchair and leaning forward when

standing. He required less assistance from the therapist for transfers and the patient’s mother

reported that her son was assisting her more with them at home.

In relation to previous research, creating a patient and family centered treatment plan that

is functional and goal oriented was successful in this case just like in others9. Using manual

techniques as seen in Bingol and colleague and Bhattacharya was also beneficial to improving

transfer assistance in a 14-year-old boy with spastic quadriplegia Cerebral Palsy. Although

during Chaovalit study they completed 75 repetitions of sit to stands the patient in this report was

able to improve safety and transfer ability completing significantly fewer repetitions when

treatment was paired with stretching, manual therapy and vibration plate therapy providing a

more well-rounded therapy session. In a systemic review with meta-analysis on the effects of

exercise intervention for children with Cerebral Palsy they found that exercises interventions

improved strength but not improved gross motor function36. Results from this case report

20
revealed that exercises interventions could lead to improved gross motor functions like the level

of assistance a 14-year-old with spastic quadriplegia Cerebral Palsy needs for transfers.

One additional finding that can be found within this study is teaching or reteaching a

patient who has been in a wheelchair long-term how to properly, and safely get out of their

wheelchair. This patient had been in a wheelchair for several years with his mother assisting with

most transfer. He got out of habit of pushing off his wheelchair and leaning forward when out as

his mother was doing most of the work. By working on cueing the patient to push of his chair, it

allowed for more functional transfers and improved patient ability to transfer himself.

The major limitation of this study is that there was only one individual in this study

completing the interventions. If more subjects were involved greater generalizability could

potentially be made compared to having one subject. Another limitation could be that the patient

in this case was receiving regular botulinum toxin injections for spasticity which may have

assisted in improving the patient’s range of motion. If the patient had not received botulinum

toxin injections the same improvements may not have been achieved. A barrier to achieving

better outcomes is that the patient was only seen one time per week per standard clinic policy,

and potentially seeing the patient twice in a week would yield further progress. Positive factors

contributing to patient’s outcomes include compliance to therapy appointments, patient’s

motivation level, and family involvement.

Future studies could look at combining multiple interventions with individuals with

Cerebral Palsy who do not receive botulinum toxin injections and see if results are similar.

Future research could also attempt these interventions with other GMFCS levels including level

5 to see if combining these treatments can create improvements for all with Cerebral Palsy. If a

study has the ability to complete treatment multiple times per week in a pediatric therapy setting

21
this could also be beneficial to see how more one on one time with a therapist working on these

tasks could contribute to improvement. One last area that could be studied is if using a vibration

therapy plates like the Galileo Med 25TT in conjunction with functional activities on it like

marching or sit to stands with standard strengthening and stretching for individuals with Cerebral

Palsy, could translate into someone with minimal ambulatory abilities like a GMFCS level 3 or 4

patient to take steps.

Overall stretching, strengthening, and vibration plate therapy could be inferred to have

contributed to patient’s outcomes. These results can contribute to the field of physical therapy by

showing that combining interventions in physical therapy and across disciplines can have

positive results on kids with Cerebral Palsy and their families and could potentially improve

functional outcomes.

22
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Table.

Exercises completed in each weekly 45-minute session

Week Therapeutic Activity Manual Therapy Neuromuscular

reeducation

1.

Evaluation

only

2.  Sit to stands from  Myofascial release of  Hooklying

wheelchair 5x bilateral quadriceps abduction step out
moderate assistance and hamstrings 5x2 mod pa
 Transitional  Functional massage on
movement- long bilateral quadriceps
sit>side> EOB x2 and hamstrings
3  Sit to stand from  Functional massage to  Galileo Med
wheelchair 7x bilateral quadriceps 25TT vibration: 3
moderate assist with and hamstrings minutes at 20hz
cues for pushing off with facilitation
wheelchair to hold feet flat
 Transition from mat trunk facilitation
to chair, and chair to to stand tall
mat x1 cues for hand minutes by 2
placement moderate therapist
assist  Bilateral quad
sets into bolster
left side 0 reps
achieved, right
side 3 reps
achieved
4  Sit to stands from  PROM bilateral knee  Hooklying
wheelchair 10x extension abduction step
moderate assist outs
 Transitional  Galileo Med
movement long 25TT vibration:
sit>side>EOB 3 minutes at 20hz
x2 with
facilitation to
hold feet flat and
trunk facilitation
to stand tall by 2
 therapist

 Bilateral quad
sets into bolster
left side x2 right
side x 3
5  Sit to stands from  Galileo Med
wheelchair x15 25TT vibration:
moderate assist 3 minutes at 20hz
x3 with
facilitation to
hold feet flat and
trunk facilitation
to stand tall by 2
therapist
6  Sit to stands from  PROM bilateral knee  Galileo Med
wheelchair x15 extension 25TT vibration: 3
moderate assist  PROM bilateral ankle minutes at 20hz
dorsiflexion x3 with
facilitation to
hold feet flat and
trunk facilitation
to stand tall by 2
therapist
7  Transition from mat  PROM bilateral knee  Bilateral quad
to chair, and chair to extension sets into bolster
mat x1 cues for hand  PROM bilateral ankle left side 3 reps
placement stand by dorsiflexion achieved, right
assist side 1 reps
 Sit to stand from achieved- patient
wheelchair x10 had hard time
moderate assist following
directions for
exercises today
 Galileo vibration:
3 minutes at 20hz
x2 with
facilitation to
hold feet flat and
trunk facilitation
to stand tall by 2
therapist- patient
became fatigued
after 2 rep
 Short arc quads
over bolster 10x
 bilaterally
8  Transition from mat  Myofascial release of  Short arc quads
to chair, and chair to right foot over bolster 10x2
mat x1 cues for hand  PROM stretching left bilaterally
placement stand by ankle and calf  Galileo Med
assist  Midfoot mobility left 25TT vibration: 3
 Sit to stand from foot minutes at 20hz
wheelchair x 15 mod x3 with
pa facilitation to
hold feet flat and
trunk facilitation
to stand tall by 2
therapist
9 Sick

10 Sick

11  Sit to stand from  PROM stretching L  Galileo Med

wheelchair 10x mod ankle and gastroc 25TT vibration 3
pa  Functional massage of minutes at 20hz x
 Knee extension push hamstrings and 2 with facilitation
outs in supine from gastrocs bilaterally to hold feet flat
hip flexion  Midfoot mobility and trunk
bilaterally feet facilitation to
stand tall by 2
therapist
 Short arc quads
over bolster 10x2
bilaterally

12  Sit to stand from  PROM stretching of  Galileo Med

wheelchair x5 bilateral lower 25TT vibration 3
extremities minutes at 20hz x
2 with facilitation
to hold feet flat
and trunk
facilitation to
stand tall by 2
therapist
Figure 1. The Gross Motor Functional Classification System is used with children to determine

the level of function that a child with Cerebral Palsy has. It also provides insight into the level of

mobility and assistive device use a child may have in

 Figure 2.

The Modified Ashworth Scale is used to determine the degree of which and individual presents

with spasticity. A score of 0 is no tone and 4 is the highest degree of tone an individual can have
Figure 3. The Galileo Med 25TT (Novatech Medical, Pforzheim, Germany). This was the

vibration plate used for the patient. The one the patient used also had a handle attached to it for

safety and support.

Appendix. Care and Comfort Questionnaire